Can a FNP in IL work and do psyc evals in outpatient settings?

Jules A, MSN · Sep 9, 2015

Hey, I was trying not to leave any intimdating juju on the threads for future clinicians. We've got to retire some day, Jules. I think the most challenging thing to do in a psych eval is to get a straight, whole story. If they're psychotic or manic then hey good luck. Otherwise, get your BS meter and spare batteries ready. You'll find them on the shelf between Saddock and Stahl. I had my own because I used to make a living shoveling BS so I'm comfortable stepping in it. You'll also soon learn that our population often has no self-insight so "how's your anxiety" is a rather challenging question for many.
There's also a faction of patients who think we know their thoughts, can interpret dreams, know what Freudian motive was behind them scratching their nose, hypnotize them, and at our pinnacle "be like Dr. Phil." I don't really tell them otherwise, lol.

You totally underestimate your past endeavors and experience with regards to the much needed skill of sorting through the BS which is crucial in psych, imo.

Where I really have the issue in non-psych people, other than the fact that my happy ass spent the time and money to actually get my PMH-NP as well as FNP is the terrible diagnosing and prescribing I see from inexperienced providers of all disciplines.

Bipolar vs PTSD vs ADHD vs ID vs Borderline vs Trauma vs SUD

Psychosis vs Delirium vs Antisocial vs Borderline vs Trauma vs Depression w/Psychotic Features vs Intoxication

Affective lability vs Mania vs ADHD vs Psychosis vs SUD vs Trauma

Just a few examples and although to a skilled clinician no big deal to the less than savvy or heaven forbid those who accept what the patients reports as fact it can be dangerous. This becomes especially concerning with those who are narcissistic enough to think they can diagnose and treat children, who btw almost never have true bipolar or psychosis.

PG2018 · Sep 9, 2015

You totally underestimate your past endeavors and experience with regards to the much needed skill of sorting through the BS which is crucial in psych, imo.
Where I really have the issue in non-psych people, other than the fact that my happy ass spent the time and money to actually get my PMH-NP as well as FNP is the terrible diagnosing and prescribing I see from inexperienced providers of all disciplines.
Bipolar vs PTSD vs ADHD vs ID vs Borderline vs Trauma vs SUD
Psychosis vs Delirium vs Antisocial vs Borderline vs Trauma vs Depression w/Psychotic Features vs Intoxication
Affective lability vs Mania vs ADHD vs Psychosis vs SUD vs Trauma
Just a few examples and although to a skilled clinician no big deal to the less than savvy or heaven forbid those who accept what the patients reports as fact it can be dangerous. This becomes especially concerning with those who are narcissistic enough to think they can diagnose and treat children, who btw almost never have true bipolar or psychosis.

Well, you're right here, and you're vastly more experienced than I am. I feel your pain. I see people get diagnosed with something, and I think "have they ever even seen a DSM?"

As I hinted before, I think kids can be challenging. There's a lot of pressure to get them medicated and stabilized coming from parents, schools, guardianships, court, etc, and a lot of diagnosticians don't properly sort through the history. That's unfortunate because they see this "oppositional" kid that's always ticked off so depending on the one doing the diagnosing it's either automatically ADHD, automatically bipolar, or this or that. I can't get past this deal of diagnosing angry people with bipolar disorder. It makes me angry! As one guy put it, "I'm always mad so my primary doctor told me I was manic." What the heck? There's no understanding of mood cycling, and these codependent providers want to medicate every iota of symptomology. I had a depressed woman tell me she still cries a couple of times a month and that I needed to increase her meds. ? These patients have been conditioned to become med seekers.

seckmann1 · Sep 9, 2015

I spoke with the company and informed them that I would be practicing outside of my scope if I did any psyc evals, but that the lines are a bit blurred regarding patient care. So, the next question is to those FNP's working under a psychiatrist, what are your job roles or functions? Are you mainly doing H&P's for new patients and maintaining medication management for the psyc meds already prescribed by your collaborating? I am a FNP-BC, with a BS in psychology, mental health therapy background and also as an RN worked in outpatient Psyc. I took the FNP route to have a broader scope, but I am going to pursue the post masters certificate in psychiatry. This company will pay for that, but in the mean time, I still don't want to practice out of my scope. Any advice?

I am trying to find a lawyer versed in this so any IL recommendations on that would be great too.

Trauma Columnist · Sep 10, 2015

I'm in IL (central IL) and though IL has not agreed to the LACE scope of practice for APRNs, the state does not have a current budget so is operating on slllllooowwww speed now.

PG2018 · Sep 10, 2015

I spoke with the company and informed them that I would be practicing outside of my scope if I did any psyc evals, but that the lines are a bit blurred regarding patient care. So, the next question is to those FNP's working under a psychiatrist, what are your job roles or functions? Are you mainly doing H&P's for new patients and maintaining medication management for the psyc meds already prescribed by your collaborating? I am a FNP-BC, with a BS in psychology, mental health therapy background and also as an RN worked in outpatient Psyc. I took the FNP route to have a broader scope, but I am going to pursue the post masters certificate in psychiatry. This company will pay for that, but in the mean time, I still don't want to practice out of my scope. Any advice?
I am trying to find a lawyer versed in this so any IL recommendations on that would be great too.

I think you're probably fine doing the medication management aspects particularly with the depression, anxiety, insomnia, etc as the majority of persons afflicted with those disorders gets treated by PCPs anyway. You'd have to be honest with yourself with regard to dosing antipsychotics - typicals versus atypicals. I assume anticonvulsants are commonplace drugs for FNPs so looking at the dosing regimens for mood stabilization shouldn't be too hard. Then look at how you'd address psychostimulants, America's new nanny, and finally the stuff PCPs quickly discard like ODD, bulimia, Autism Spectrum, Tourette's, et al. Do you really feel equipped to tease through autism spectrum vs. OCD vs. ODD vs. ADHD vs bipolarity. I see this as most difficult for me because I have never really worked with kids in any capacity prior to my present employment, and my child exposure during PMHNP training was just enough to fill the requirements. I see a lot of NPs, both psych and family, relegated to only med checks. Some psychiatrists assert that they aren't qualified to do the evals (BS), but it's merely a matter of economy. A true psych eval yields good revenue. Medicaid, our highest overall reimbursement and also the most common among SMI/SED, here pays $120/eval, and I can do at least two of those in the time it takes me to do four 99213s (@ 29.04/appt.) which yields a net loss of > $120/hr. I love evals. The more the merrier. I wouldn't mind subbing out my med checks to a FNP to focus more on evals, lol. In the end though I think diagnosing is easier than medicating.

Jules A, MSN · Sep 10, 2015

I think diagnosing and prescribing are equally challenging but my pharm courses were rather deficient so perhaps you had a better experience. I still rely heavily on the years I spent doling out pills as a RN. I'm not sure I'd work where I was relegated to only continuing medications and I would imagine a FNP who is doing that with a physician who is a lousy prescriber, tons out there imo, would be at risk. I'm doubtful that a court would be too enamored by the excuse that "I was only continuing what they ordered".

Do you really feel equipped to tease through autism spectrum vs. OCD vs. ODD vs. ADHD vs bipolarity. I see this as most difficult for me because I have never really worked with kids in any capacity prior to my present employment, and my child exposure during PMHNP training was just enough to fill the requirements.

This is an excellent point and I was fortunate enough to have worked on a pediatric and adolescent inpatient neuro psych unit so I can see them coming a mile away. Especially on an outpatient basis being able to quickly identify the patients, often with anger and legal struggles, who present as irritable, assaultive and overly defensive but are actually intellectually disabled is a major plus. Ask about their education, special ed?, trauma history, look for poor self esteem and concrete thought process. This is one of my favorite populations and in many, not all, cases being able to understand where they are coming from and not being afraid to skillfully prescribe polypharmacy as indicated is going to be the key.

seckmann1 · Sep 12, 2015

I did consult with a lawyer and he stated that it would be practicing outside of the scope of a family nurse practitioner to do psyc evals. Just for anyone wanting to know! I was told by the company several times that it was okay, but just had to listen to my gut and get legal advice.

Jules A, MSN · Sep 12, 2015

I did consult with a lawyer and he stated that it would be practicing outside of the scope of a family nurse practitioner to do psyc evals. Just for anyone wanting to know! I was told by the company several times that it was okay, but just had to listen to my gut and get legal advice.

You are smart. I find too many people want to hear what they want to believe and make very foolish choices because they aren't willing to see the writing on the wall.

seckmann1 · Sep 13, 2015

I found this to be helpful from http://www.medscape.org/viewarticle/506277_7

"Is it within the scope for an FNP to diagnose and treat uncomplicated mental health conditions like depression, anxiety, and ADHD?The answer is yes, in the context of primary care, and at the level of competency and skill expected for the FNP standard of practice. The context of primary care means that you are seeing this patient for health needs and the depression or anxiety is clearly diagnosed to be situational, acute, and/or potentially responsive to medications. The competency and skill preparing the FNP for practice does not include differential diagnosis of complexities such as unipolar vs bipolar depression, or anxiety related to underlying psychiatric conditions as an example. If you are prescribing medications for a condition that you cannot clearly diagnose (or support the established diagnosis with documentation), treat, follow, and monitor to a level or stabilization and beyond, you are practicing outside of your scope. Atypical or off-label prescribing for a mental health condition would be considered a subspecialty role requiring greater expertise and competencies.

Most practice acts provide for time-limited stabilization of a patient or continuation of psychiatric medications that a patient has been taking for a diagnosed condition. Initiating diagnosis of a complex condition that has consequences for schooling, job, and military records, such as ADHD, is out of the scope of training and competency for the typically educated FNP. Collaboratively arriving at a diagnosis and treatment plan with a mental health provider trained and licensed to diagnose mental health conditions may be one possibility for initial diagnosis and for periodic management.

There have been several licensing disciplinary cases related to both FNPs treating mental health conditions and PMHNPs treating primary care conditions. In the case of the FNPs, many were not licensed or clinically trained to differentially diagnose beyond the very basic self-limited mental health conditions, yet had prescribed medications such as antipsychotics or had mistakenly given selective serotonin reuptake inhibitors to patients with mood disorders who they thought had simple self-limited depression. Lack of access to mental health providers (or primary providers) may be an issue, but it does not change the requirement to get your patient to the most appropriate provider to coordinate their care. For the PMHNP, coordinating or initiating treatment for primary care conditions without the knowledge of a primary care provider can be a significant area of risk to the patient and to your license."

AtomicWoman · Sep 20, 2015

I did consult with a lawyer and he stated that it would be practicing outside of the scope of a family nurse practitioner to do psyc evals. Just for anyone wanting to know! I was told by the company several times that it was okay, but just had to listen to my gut and get legal advice.

You is one smart kitty. :cat: